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Proceedings 



\ M ,\ 



AMA 
AAMVA 



HV5701 

P941 



National Conference 



Telescopic Devices 



Driving 




WASHINGTON, D.C. 

V JUNE 11 - 12 
\ 1976 







SPONSORED BY: 



American Medical Association 

535 North Dearborn Street 
Chicago, Illinois 60610 



American Association of 
Motor Vehicle Administrators 

1201 Connecticut Avenue, N.W. 
Washington, D.C. 20036 



ACKNOWLEDGEMENTS 

The American Medical Association and the American Association of 
Motor Vehicle Administrators are grateful to all of the organizations 
and individuals contributing to the success of the 1976 National Con- 
ference on Telescopic Devices and Driving. 

Initially, we wish to thank Paul V. Joliet, M.D., Conference 
Chairman, and John D. States, M.D., and Milo Hodgson, Chairmen of the 
workshop sessions, all of whom carried out their difficult assignments 
with skill and patience. 

The four speakers who also spent so freely of their time and 
energy to prepare formal papers for presentation deserve the fullest 
appreciation from all of us--each of them did precisely what was 
asked of them, namely: provide background information and "prime the 
pump" for the workshop sessions. In including their papers in these 
Proceedings, we are happy that it will be possible for many more per- 
sons than could attend in person to benefit from the excellent 
material presented. 

Finally, we thank all the participants who contributed thoughts, 
suggestions and solutions. Whatever results do finally accrue, we 
know that participants came up with the ideas that started the process 



Price: $3.50 each, prepaid. 
Quantity prices on request. Send 
check or money order to Health and 
Safety Associates, P.O. Box 222, 
Morton Grove, Illinois 60053. 
Copyright, HSA, Inc., 1976. 



n 



PREFACE 



The use of telescopic devices (lenses, spectacles, telescopes, 
magnifiers) while driving has become a controversial issue in recent 
years. Driver licensing officials in many states have been confronted 
with the problem of whether or not they should license an individual 
who is able to pass the visual acuity standard with the aid of a tele- 
scopic device, but who does not have the required acuity when driving 
without using the device. Since wearers of telescopic devices use them 
for only short periods while driving, the problem for licensing of- 
ficials, legislators and the general public is obvious. This Confer- 
ence was developed to provide a national platform for airing all 
facets of the issue, and develop recommendations that will aid li- 
censing officials in administering a policy that is not only fair to 
the user of telescopic devices but that will insure the safety of the 
user as well as that of society generally. 

The background materials prepared for this Conference pointed 
out that a Workshop sponsored by the New York Department of Motor 
Vehicles did not have available to it sufficient expertise for dis- 
cussion of the inherent limitations of telescopic devices for driving, 
although the final report did avail itself of the general literature 
on the subject. A brief summary of that report has been included in 
these Proceedings. 

Space does not permit the inclusion of the workshop discussions. 
We trust, however, that the tenor of the discussions has been faith- 
fully reflected in the Conference Recommendations. 

These Proceedings contain the names and addresses of all who 
registered. Without these individuals these Proceedings would not 
exist, but that is not the reason for their inclusion. Actually, the 
persons listed, and the organizations they work for, represent the 
core of much of what will be done in regard to those with low vision 
problems for many years to come. 

Obviously, the recommendations presented herein have tremendous 
potential, but ideas and recommendations, no matter how good, are not 
implementation. Usually it is not within the scope of a preface to 
plead a cause, but in this case we cannot help but feel that everyone 
who is the least bit interested in either persons with visual impair- 
ment or the field of traffic safety generally should do what he or she 
can do to aid in such implementation. 



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TABLE OF CONTENTS 

PREFACE iii 

CONFERENCE PRESENTATIONS 1 

Introductory Remarks 3 

Paul V. Joliet, M.D.* 

Limitations of Telescopic Spectacles 5 

Gerald E. Fonda, M.D. 

Recent Developments in Bioptic Aids for Driving 9 

William Feinbloom, O.D. 

Adaptation and Other Considerations in 

Driving with Low Vision 19 

Dennis Kelleher, Ed.D. 

Practical Concerns in Driving with Subnormal Vision, 

Criteria for Introducing New Devices 25 

Arthur H. Keeney, M.D., D.Sc. 

RECOMMENDATIONS 31 

APPENDIX 35 

A. Additional References 36 

B. New York Workshop Report 37 

C. List of Participants 39 



*Speakers, as well as all registrants, are identified in the Appendix 



CONFERENCE 
PRESENTATIONS 



INTRODUCTORY REMARKS 
Paul V. Joliet, M.D., General Chairman 



Since I am certain that all of you came here, as I did, to learn 
more about the use of telescopic lenses in driving, I am going to 
keep my comments wery brief. 

I do, however, want to say a word about this meeting and the 
manner in which it has been set up. Those of you who have done your 
homework and read the background materials that were sent to you under- 
stand the relationship of this meeting to the workshop on the same sub- 
ject in New York just about a year ago, and also that there is a certain 
amount of disagreement concerning the answers we all seek. I believe, 
however, that even if we can't agree on definite solutions, we can 
agree on the direction we turn to get those solutions. 

I have attended safety conferences and workshops for many years-- 
more than I care to admit— and I can assure you that at those sponsored 
jointly by the American Medical Association and the American Association 
of Motor Vehicle Administrators, I have always gone back home with a 
sense of accomplishment. As you note from your program, we are starting 
out with a number of presentations that should certainly provide ex- 
cellent background material, although I am certain that everyone will 
not agree on the interpretation of that material. 

Then we come to the workshops where all of you will have the op- 
portunity for input, and we want exactly that. The workshop chairmen 
really have only one instruction, and that is give each of you a chance 
to say your piece. Perhaps we might even be able to come up with con- 
sensus. 



LIMITATIONS OF TELESCOPIC SPECTACLES 

Gerald Fonda, M.D. 

In my opinion, telescopic spectacles, including the Feinbloom 
bioptic, are grossly overrated as a useful optical aid. Many thou- 
sands of telescopic spectacles have been promoted, but the only ad- 
vantage of a telescopic spectacle is that it produces a magnification 
ranging from two to three times. . In discussing telescopic spectacles, 
it must be understood that there are different problems involved in 
wearing full field telescopic spectacles and the bioptic telescopic 
spectacle. 

FULL-FIELD TELESCOPIC SPECTACLES 

The more important of the limitations of full-field telescopic 
spectacles involve a constriction of visual field to less than 20°; the 
creation of an illusion making objects appear closer and larger; a 
faulty projection showing objects to appear where they are not; an im- 
pairing of depth perception; a magnification of motion, and a displace- 
ment of objects in opposite direction to movement of head. 

In examining these limitations, it should be noted that constric- 
tion of the visual field to less than 20° puts the wearer in the 
legally blind category. And the handicap is more severe than the 
slowly progressing constriction of some eye diseases that allow the 
patient time to adjust; since the constriction is sudden and abrupt 
ewery time a patient shifts to telescopic spectacles from the carrier 
lenses. 

The apparent nearness, magnification, and faulty projection of 
what is viewed through the spectacles make it \/ery difficult for the 
wearer to judge distances, speed, or precise location of other vehi- 
cles, highway hazards, pedestrians, bicyclists or animals. Added to 
these difficulties are the obvious hazards of having the already con- 
fusing motion of vehicles on the streets and highways intensified and 
seeming to move in an opposite direction to the motion of the head. 

To learn first hand the visual experience of walking with tele- 
scopic spectacles, and also why wearers cannot use them continually 
while traveling, I had a pair of 2.2x Kollmorgan telescopic spectacles 
made for myself in 1956. In trying to adjust to them in my home, I 
first noticed that I could not see the width of the door; next I felt 
that I might fall down the steps because they appeared big and close. 
During a mile walk, I was continually aware of the magnification and 
closeness of objects as well as the magnified motion when I moved my 
head. Worst of all was crossing a one-way street without much traffic 



on a Sunday morning. Although legally blind (20/200), it was a great 
relief and increase in security for me to take off the telescopic 
spectacles and walk home without glasses. Admittedly, with more ex- 
perience and over a familiar course, it would not have been quite so 
terrifying, but imagine the problems of travel in an automobilel 

BIOPTIC TELESCOPIC SPECTACLES (Feinbloom 3x) 

This device is worn at the top of the spectacle (Figure 1) so that 
the wearer's peripheral vision area beyond 20° is not blocked. How- 
ever, the central field is constricted to 7°, and there is a blind ring 
area of 12° in diameter around the central field (Figure 2). Other 
limitations are: difficulty of achieving and maintaining binocular 
vision (actually experienced by less than 20% of drivers), especially 
in moving city traffic where traffic is heavy and distances are close; 
difficulty of finding objects through rear view mirrors; displacement 
through lens of objects in opposite direction to movement of head, while 
rest of environment observed through carrier lens remains stationary; 
objects appear closer, larger, and motion is magnified; depth perception 
is impaired, especially when only one unit is used; vibration effects in 
a moving vehicle are severe; difficulty of extending neck to use tele- 
scope increases fatigue, and difficulty of shifting fixation to and 
from spectacle to telescopic unit and vice versa. 

Let's expand upon some of those limitations. First of all, the 
central field constriction of 7° is equivalent to a diameter of 24 feet 
at a distance of 200 feet. This is about half the width of the usual 
city street. In addition, at 200 feet there is a blind area of 42 feet 
in diameter around the central magnified area of 24 feet, resulting in 
a blind area on each side of the area straight ahead that is almost 
twice the width of the area magnified. Thus the total blind area is 
more than three times that of the area seen (84' to 24' ). 

The location of objects with a constricted field of 7° is indeed 
difficult in that at 50 feet the constriction is down to 6 feet, just 
about the width of a car. This is especially crucial in rapidly 
moving traffic where cars are passing and changing lanes. Furthermore, 
most drivers do not achieve binocular vision. 

The matter of using the rear view mirror is a difficult problem in 
that the mirror is within two feet of the driver, making his 7° field 
three inches in diameter. This causes a delay in changing fixation. 
How long does a driver have to find a three-inch area, picture the 
problem, make a decision and then initiate some action? In high-speed 
traffic, the time allowed for anyone is pitifully small--for drivers 
with bioptic telescopic spectacles that available time is considerably 
less. I believe hazardously so. 

The confusion of objects moving in the opposite direction to move- 
ment of the head that occurs in the full-field telescopic spectacle is 
even more serious in the bioptic, because the rest of the environment 
observed through the carrier lens remains stationary. In addition to all 



of these difficulties, there is the difficulty of constantly shifting 
fixation between telescope and spectacle. Such shifting produces con- 
stant changes in magnification of 300 percent. 

Personally, driving while wearing my 3x bioptic telescopic spec- 
tacle has created a series of frightening experiences for me. Viewing 
the magnified, apparently close width of the road (24 feet) is serious 
in itself, but to be blinded for an area of 42 feet in width on each 
side more than compounds the hazard. This excludes from view the side 
of the road, sidewalks and driveways, at a distance of 200 feet. At a 
distance of 50 feet, the central field is constricted to width of the 
car ahead of me (6 feet), and blinds out the oncoming traffic on the 
left and the edge of the road on the right (each area 10 feet in width). 

I found the telescopic spectacle unit useless at an intersection 
when I wanted to see the cars and pedestrians before I crossed or 
turned, and I am not able to read the speedometer or other gauges on 
the instrument panel. 

I am definitely more confident and relaxed driving without my 
glasses with vision of 20/200, but I would not think of driving with 
this vision even under the best lighting conditions--!! could not read 
the road signs, recognize one-way turns, traffic lights, darting 
children or determine when a car ahead is parked or in slow motion. 
To drive toward the sun, in rain, at dusk or at night would surely 
invite disaster. 

CORRECTING TWO COMMON MISAPPREHENSIONS 

The matter of adjusting to the magnification of a bioptic telescope 
has been compared in some literature on the subject to adjusting to 
cataract spectacles. There is no comparison since the magnification of 
cataract lenses averages about 25%, whereas the magnification of the 3x 
bioptic telescopic is 300%. In addition, the patient who has been 
operated on for a cataract wears his glasses continuously whereas the 
bioptic telescope is used infrequently. The adjustment to the 25% 
magnification is usually made in one week. The adjustment to the 300% 
magnification of the 3x bioptic is never made for continuous use. 
Shifting fixation from the carrier lens to the small magnified area of 
300% through a wide blind area is completely different. 

Also compared has been the blind ring area of 12° in the central 
field of the bioptic with the "Jack in the Box" phenomenon in a 
cataract lens. These cannot be compared either since the latter is a 
prismatic displacement which is only infrequently noticed and which 
occurs at a distance of at least 60° in the periphery. 

I would like to close by stating that the advantage of the periph- 
eral field of the Feinbloom bioptic telescopic spectacle is offset by 
a central magnified field of only 7° and a combined blind ring area of 
24°. Under driving conditions this means that at a distance of 200 feet 
the area seen through the telescope is 24 feet in diameter and a blind 



area on each side of 42 feet in diameter. To see only the constricted 
magnified area of three times the width of an automobile is serious in 
itself, but to also be blinded on the right to everything on the side of 
the road, as well as to be blinded on the left side to on-coming traffic, 
is doubly hazardous. 



Fonda - Figure 1 



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Fonda - Figure 2 



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CENTRAL flELD 8 RING SCOTOMA WITH FEIN8L00M 2.2x BKPTtC TELESCOPE 








Field thru Telescope * 7° 
Ring Scoforno due fo Edges of Telescopic Unit'12 9 



RECENT DEVELOPMENTS IN BIOPTIC AIDS FOR DRIVING 
William Feinbloom, O.D., Ph.D. 



Safe driving is a performance of many sensory, physical and psycho- 
logical skills. It is self-evident that vision is vital to the proper 
performance of these skills, especially since improvement of these 
skills depends upon repeated practice periods, each of which utilizes 
vision. 

What is not so evident, however, is how the different aspects of 
vision function are specifically related to safe driving. 

In considering the development of bioptics for driving, we have 
tried to design them in such a way that the low vision driver who at- 
tains 20/40 vision with the bioptics should be able to acquire the same 
degree of skills necessary for safe driving. 

Let us first examine the aspect of vision we call Visual Acuity. 
At this time let us look at slides #1, 2, 3, 4, 5, and 6. These are 
photos of the actual bioptics that are being used in driving. They show 
the following bioptics--the 2.2x standard, the 2.2x wide angle, the 
3. Ox standard, the 3. Ox wide angle, the 4. Ox standard and the new 4. Ox 
prism systems. Slide 7 gives the optical field and ring scotoma for 
each system. 

Let us now examine one of the most important aspects; namely, 
Visual Acuity. The curve for visual acuity over the entire retina is 
greatly skewed as is well known; however, what is not commonly appre- 
ciated are the careful measurements done by Jones & Higgins in 1947, 
which show (slide 8) that 20/40 visual acuity exists within 1° at the 
fovea out of the entire 135° monocular field of vision in the normal 
eye.' This same normal 20/40 driver not only uses his central 1° vision 
in each eye, but all of the retinal V.A. throughout the 180°, that 
interact simultaneously with the central acuity. He cannot ever 
separate the two visual acuity areas, even though the extreme periphery 
has a V.A. of 20/2000. 

The same type of continuous V.A. use of center and periphery 
exists while using the bioptic. It is surprising to notice when one 
is teaching the bioptic patient how to observe both centrally and 
peripherally simultaneously, that there is indeed an individual dif- 
ference between drivers in becoming aware of this and learning to do 
this consciously and well. 

Mourant and Rockwell in 1972 conducted a study, "Strategies of 
Visual Search by Novice and Experienced Drivers," where they measured 



and compared the eye movements of the two groups of drivers as they 
performed driving tasks such as approaching a stop sign, approaching 
a traffic signal, and making right and left turns. 2 There were two 
driving routes, one through a neighborhood, the other on a freeway. 
Much interesting data was obtained relative to the difference between 
the use of central vs. peripheral vision. The authors state, "A 
novice driver samples considerable information foveally, that the 
experienced driver obtains through peripheral vision. Thus, novice 
drivers must learn to recognize objects and their relationships with 
peripheral vision. Unfortunately, little is known about how long it 
takes to learn to use peripheral vision." 

The bioptic is so designed that while the driver fixates the cars 
directly ahead, he can view the lane markings and through the periphery 
simultaneously fix other vehicles' lane positions, directions, and 
relative speeds of travel. 

In the paper, "A Look at Driving with Bioptic Telescopic Spec- 
tacles," the present author reported in 1975 on 300 cases fitted with 
bi optics for driving. 3 Each driver drove with bioptics from 2 to 18 
years. The annual mileage ranged from 4,000 to 45,000 miles and 
averaged 12,500. Their reported experiences show that they are aware 
of the need for conscious monitoring of both central and peripheral 
field of vision. 

In designing the bioptic, provisions were made to allow central 
fixation either through the bioptic or carrier while peripheral vision 
exists at all times. The bioptic part itself is used differently by 
different patients. Some use it only as a spotting device to see re- 
quired detail of 20/40 V.A., others use it much more frequently as a 
way of monitoring more if not all of the central fixations. How the 
bioptic is best integrated by the individual person depends on both 
personal factors and training. The closeness illusion while particular- 
ly noticeable when not in motion, is more quickly adjusted to when 
driving, because the peripheral field is properly positioned and serves 
as a reference plane for true distance judgment. 

When the low vision driver looks through the carrier below the 
bioptic his central V.A. drops to his regular spectacle acuity, i.e., 
20/200 or better, but less than 20/40. To test the possibility of 
driving with 20/200 vision, the present author, in the paper "Tele- 
scopic Lens Systems and Driver Licensing" in 1975, presented at the 
Conference sponsored by the New York State Department of Motor Vehicles, 
reported the experiment (slide 9) with 12 normal-sighted experienced 
drivers, whose normal vision was fogged with a pair of +3.00 fitover 
goggles so that their vision was blurred to less than 20/200 (slide 10). 4 
Each person drove for periods of from 1 to 4 hours at a time, for a 
total of 10 hours. They drove during one week in the month of March 
in all kinds of traffic and weather, both in daylight and at night. 
They drove in the city, the country, suburbs and state highways. 
They encountered good weather, rain and storm. No special instruc- 
tions were given prior to initial daylight driving. 



10 



Their reports were all quite similar. They made almost instant 
adjustments to their reduced V.A. and blur. 

They had no difficulty, in viewing traffic in front, the sides or 
through the side or rear-view mirror. They drove at 55 miles per hour 
on the highway and had no problems with lane position, or changing 
lanes. In country and city driving they could see traffic lights well, 
and pedestrians, motorcycles, bicycles and animals entering their 
danger zones. They could park along curbs or in designated parking 
areas. 

These experiments with the +3.00 blur to 20/200 have not been 
repeated by many practitioners in order to experience for themselves 
the feasibility of driving with 20/200 V.A. and normal field of 
vision. 

However, these same experimenters reported they could not read 
any signs, either on the state highway, city streets, town or country 
roads. In other words, the central 1°, 20/40 V.A. is required for 
the resolution of printed material of objects of such size as cor- 
responds to 20/40 vision. 

Another aspect of vision that was considered in the design of 
the bioptic is that of fixations away from the median line. The 
driver with bioptics, just as the normal sighted driver, is first 
made aware of "danger" when something new and possibly dangerous ap- 
pears in the periphery of the driving scene. Both types of drivers 
then make a head-eye movement, to fixate the interested area in the 
periphery. 

(Slide 11) Robinson, in his study "Visual search by automobile 
driver" found that with normal vision drivers, the head starts turning 
within £15 seconds once the eye starts for a peripheral fixation point 
the eye can rotate at an angular velocity of 1000O per second and the 
head at the speed of 450° per second. 5 in the stationary position of 
testing, as in Robinson's experiment, the eye starts rotating at once 
and the head starts .05 seconds later; the eye stops rotating when the 
fixation target reaches about 35° and is simply carried along by the 
head up to about 60°. After 60° body rotations occur as well as head 
and eye. 

In a similar type of study reported at the American Academy of 
Optometry meeting in 1972, we measured the head and eye dynamics while 
the subject drove his car at 55 miles per hour. 

The design of apparatus used !s shown in slide 12. The eye 
perimeter allowed for fixations from zero to 70° since the windshield 
itself only subtends 70° to the right temporal side. The subject had 
to fixate the targets by properly reading 2 digit numbers of 20/40 
size at one meter. While he was making an eye fixation, his head move- 
ment was measured. The difference between the angle of fixation and 
the head rotation gave the degree of eye rotation. 



11 



The resulting data is similar to Robinson's except that eye move- 
ment did not exceed 20° rotation. 

In prescribing the bioptic we instruct the patient to conscious- 
ly start head movement as soon as fixation is called for. We train 
him by periodic exercises on peripheral fixations and refixations or 
a single horizontal line number chart placed 20 feet from him. He does 
this exercise for 10 to 15 minutes at a time, preferably outdoors 
while wearing his bi optics. 

The judgment of position and distance through the bioptic is dif- 
ferent when the driver observes a stationary scene as compared to a 
moving scene. This is especially true after some experience in driving 
with bioptics. That this can occur in the visual experience is not so 
surprising when we think of the normal vision driver using his rear- 
view mirror. When he drives, the cars seen in the rear-view mirror are 
always projected to his rear. In spite of the fact that the image of 
the car actually is in front of his own car, he transposes the rear 
car's position to be behind him. He cannot by any normal effort make 
the rear car appear in front of him. 

However, if he parks his car at the curb and studies the cars 
parked behind him in the rear mirror he soon can sense the mirror 
image of cars as being in front of him. In other words, perception 
of optical images are different when the observer or environment is in 
motion as compared when everything is stationary. Probably all of 
vision is different in situations of motion. 

When the normal sighted or bioptic driver uses the rear-view or 
side-view mirrors, he must also make adjustments of position with 
regard to horizontal and vertical displacement as well as front to 
rear, The image of a car in the left side-view mirror is usually dis- 
placed 10 to 15 feet more to the left than it actually is and from 10 
to 20 feet lower than when the same car is viewed in the rear-view 
mirror. 

This ability to maintain the identity of an object and its rela- 
tive position during motion perception is what Kolers refers to as 
"Figural Identity. "° He points out that, "the eyes move continuously, 
yet figures retain their shapes, and objects retain their position in 
perceptual space." The low vision bioptic driver can adapt to the 
use of the bioptics as the normal driver can adapt to the use of the 
rear and side-view mirrors. 

The design of the bioptic as an optical system does produce a 
ring scotoma around the central field of vision. This occurs because 
the physical mounting holding the optics in place subtends a larger 
angle than the optical field itself. 

The ring scotoma is more real in the static laboratory situation 
than in the dynamic one when driving where the head and eyes are con- 
stantly changing fixation. 



12 



In order to understand why such blind spot scotomas are not 
significant to bioptic drivers, and how their perception deals with 
this problem, let us look at the blind spot problem ever present in 
all cars that normal drivers have to contend with (slide 13). 

Here we see that a driver looking forward through the windshield 
is confronted with normal blind spots of 7° in each eye, as well as a 
10° blind spot due to the left hand post supporting the windshield, at 
about 45° to the left, and a blind spot of 5° at about 70° to the right 
due to the right hand post. In addition, the entire rear area is all 
blind except for 30° seen through the rear-view mirror and 9° seen 
through the side-view mirror. The normal driver learns to deal with 
all these blind spots through experience. 

Slide 14 also shows the same scene for the bioptic driver, and 
we see that these ring scotomas overlap the normal blind spot areas 
on the temporal side, and the driver deals with these very much as 
he does with his normal blind spots. Where binocular vision exists, 
the vision in each eye will overlap and cancel out the nasal side of 
the scotoma of the other eye. 

Two additional criticisms have been raised by both Fonda and 
Keeney. ' The first of these is the presence of the "Jack in the 
Box" effect as an overtaking car passes from the field of the carrier 
into the field of the bioptic, or similarly when a car traveling at 
right angles to the driver passes in front of him and so again is 
seen first in the carrier and then in the bioptic field and lastly 
out into the carrier again. 

The "Jack in the Box" phenomenon is well known to every driver. 
It is the sudden rude awakening that one experiences as an overtaking 
car rushes past the unsuspecting driver in an adjoining lane. The 
reason for the driver's alarm is that the image of this car has 
suddenly appeared ostensibly out of nowhere, i.e., from behind his 
peripheral vision, and appears to be dashing madly forward into his 
central field. Had the driver been monitoring the rear and side- 
view mirrors, and so been made aware of this hastily approaching car 
in the process of overtaking him, he would have developed a "set" for 
the car's appearance and thus minimized the shock of its appearance. 

This "Jack in the Box" effect also operates when the driver uses 
bioptics as the overtaking car is seen first in the peripheral carrier 
vision and then in the bioptic field. However, the effect is not as 
disturbing because the driver is already set since the car is always 
first seen in the peripheral carrier section. The same effect occurs 
when the bioptic driver awaits or encounters cross traffic at inter- 
sections. Here, too, however, the driver's adjustment takes place 
quickly because of his inherent knowledge of the fact that the 
approaching car traveling at a given speed in the carrier field will 
momentarily zoom through the bioptic field. The driver correctly in- 
terprets the illusion and integrates the scene as a total gestalt. 
To the driver wearing bioptics the "Jack in the Box" effect soon be- 



13 



comes as much an integral part of the driving experience as it does to 
the normal driver. 

The second objection raised is that "objects seen through the 
bioptic field are displaced in an opposite direction to any head 
movement." This objection is in error, because all objects seen with 
or without any type of corrective lenses are always displaced in an 
opposite direction to any head movement. Most times people are 
totally unaware of this opposite motion displacement because it 
occurs slowly. What does occur with bioptics is that the apparent 
speed of a car seen in this field is greater, so that the driver is 
aware of this "opposite" movement. However, as we noted above, he 
soon adjusts to this apparent increase in speed. 



References 



1. Loyd A. Jones and George C. Higgins: Some Characteristics 
of the Visual System of Importance in the Evaluation of Graininess 
and Granularity. Journal of the Optical Society of America 1947, 
Volume 37, No. 4, 217-263. 

2. Ronald R. Mourant and Thomas H. Rockwell: Strategies of 
Visual Search by Novice and Experienced Drivers. Human Factors 1972, 
14 (4) 325-335. 

3. William A. Feinbloom: A Look at Driving with Bioptic 
Telescopic Spectacles—presented at the Low Vision section. American 
Academy of Optometry Meeting in Columbus, Ohio. Soon to be published. 

4. Telescopic Lens Systems and Driver Licensing, by Safety 
Management Institute, Washington, D.C., for New York State Department 
of Motor Vehicles, May 1974. 

5. Gordon H. Robinson, Donald J. Erickson, Gregory I. Thurson 
and Richard L. Clark: Visual Search by Automobile Drivers. Human 
Factors 1972, 14 (4), 315-323. 

6. Paul A. Kohlers: Aspects of Motion Perception. Pergamon 
Press, New York. 1972, 41-44. 

7. Gerald Fonda: Bioptic Telescopic Spectacles for Driving 
Motor Vehicles. Archives of Ophthalmology October 1974, Volume 92. 

8. Arthur H. Keeney: Field Loss vs. Central Magnification. 
Archives of Ophthalmology October 1974, Volume 92. 



14 



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page 17 



14. 



ADAPTATION AND OTHER CONSIDERATIONS 
IN DRIVING WITH LOW VISION 



Dennis Kelleher, Ed.D. 



Unfortunately, there is currently no statistically significant 
data regarding the role of vision in driving. As a result, when an 
individual doesn't meet the present vision screening standards, even 
though they may be arbitrary and based on "educated opinion," there is 
apprehension and misunderstanding. Though we only have a few incidents 
of persons with low vision safely and successfully operating motor 
vehicles, it certainly raises the question of how valid are our present 
vision screening standards? Everyone agrees that not all persons with 
low vision could drive safely, but the difficulty arises when we must 
select the small minority of persons who could be successful. The main 
reason for concern is naturally what is best for the public welfare. 
Finding out more about the role of vision in driving not only has im- 
plications for the low vision population, but the entire driving popu- 
lation as well . 

Several states have licensed low vision patients to drive with 
varying restrictions. In most instances, persons have been carefully 
screened and selected through mutual cooperation between the state 
licensing agency and eye care professionals. Prerequisites for 
selection usually include specific visual acuity and visual field 
levels, ocular motility, stable eye condition, and patient need to 
drive for business or school. It's certainly difficult, if not im- 
possible, to place every conceivable restriction on a license so it 
is naturally desirable to select applicants who have a high sense of 
moral responsibility and who will voluntarily restrict themselves from 
driving in situations they know to be hazardous. 

Since we see with our brain and not our eyes, our next considera- 
tion becomes, can training and adaptation overcome some of the prob- 
lems involved in driving with low vision? Before we can consider this 
question, we must first focus on a particular device, namely the bioptic 
telescope, since it is the aid most widely used and has much different 
characteristics than driving with a telecon (contact lens-spectacle 
telescopic system) or driving with merely standard glasses with a visual 
acuity of say 20/100 constantly. 

In considering the bioptic telescope, I feel we should clarify 
some misunderstandings as to its advantages and disadvantages. The 
bioptic is used as a spotting system only and never constantly; so a 
person is driving with his low vision during the majority of the time. 
The amount of time one will use a bioptic will vary according to the 
needs of the particular driving situation, e.g., more when one must 



19 



distinguish distant details, less when one is in need of a wide visual 
field. 

Is driving with 20/100 safe? My experiences in all types of 
situations for 70,000 miles have been thus far, as have those of many 
other low vision patients. The important question becomes, why? 

We have research data from a number of sources, Thomas, Kalunger 
& Smith, 2 and Berg & Henderson, 3 to name a few, that tell us 
"normally sighted (20/20) drivers do not resolve 20/20 detail on a 
continuing basis. The eye fixes on many things of which the viewer is 
not aware. Acuity is used either as a response to low resolution 
stimuli or as the result of a conscious decision by the driver." Con- 
ducting a replica study and arriving at the same conclusions as these 
studies would explain how a low vision patient could use a bi optic 
telescope as a "pseudo-fovea" when high resolution was necessary. Of 
course, this is assuming that the low vision patient suffers from re- 
duced vision due to an underdeveloped macula and has normal peripheral 
retinas which seems to be the case so far in examining the types of 
etiologies licensed to drive. 

In driving, we are talking about dynamic visual acuity as opposed 
to static visual acuity. If we choose to believe the above research, 
and persons will believe what they want to believe regardless of 
statistical data, it is likely that much lower visual acuity levels are 
used in driving than we presently screen for. 

One certainly doesn't have to resolve a target in detail to react 
to it. Everyone glances at a clock without foveal fixation very often, 
yet they know the time by the position of the hands. 

A 4' child subtends a visual angle larger than 20/200 at 1200 
feet. If one were going 50 miles per hour, 73 feet per second, a 
driver would have 16.5 seconds to see this object which would have a 
constantly larger visual angle and react to it. 

One opinion which has been stated as a "fact" erroneously is 
that a normally sighted person can, by removing glasses which correct 
a refractive error, duplicate low vision. This is inaccurate because 
in-focus light rays not being properly transmitted or processed by an 
underdeveloped macula is not the same as out-of- focus light rays' 
reaching a normal retina. Also, a low vision patient's brain is 
accustomed to processing a substandard visual image and has most likely 
learned to compensate far in excess of what the normally sighted brain 
can do during a 30-minute episode. 

Let us consider other limitations and the brain's ability to com- 
pensate for them. There is no argument that there is a reduced visual 
field through a telescope and this field decreases as the magnification 
increases. The 3. Ox Designs for Vision Bioptic has only an 8° field, 
but the fovea is only equivalent to a 3° to 5° field in the normally 
sighted person! 



20 



The ring scotoma, the blind area surrounding the telescopic 
field caused by the housing, has been reported in the literature as 12 
and as a hazard in driving. The concern is that an object could be 
obscured in this ring scotoma. First of all, this has never posed any 
problem to myself or any other bioptic driver I have discussed this 
with. Why? Because in a car you are moving. Objects around you are 
generally moving. As you approach objects, the angular subtense 
changes, hence it would be virtually impossible to "lose" any object in 
a scotoma for any length of time unless it were moving in the same 
direction at the same speed to maintain distance, in which case no haz- 
ard would exist. Even under these unusual circumstances, if a person 
is using his bioptic properly, he will make several fixations (one 
fixation for the average person takes about .25 seconds) while main- 
taining peripheral vision around the bioptic. The patient will then 
fixate through the carrier lens and notice the object if he hasn't 
already been aware of it. One can observe that even the normally 
sighted driver can make a limited number of fixations and hence cannot 
possibly resolve with 20/20 acuity e\/ery object of importance while 
driving. Secondly, everyone deals with scotomas without any problem 
constantly.. .by the brain ignoring them. For example, the rear view 
mirror or the windshield post is a scotoma. The one-eyed patient 
never complains about problems in coping with his physiological blind 
spot. When considering head, eye, object and body movement, it creates 
a dynamic situation which reduces the problems caused by a blind spot 
in a static situation. 

There is no problem in using mirrors with a bioptic since the 
image in the mirror will appear at optical infinity if the object (as 
is most often the case in driving) is further than 20 feet from the 
mirror. I use a wide angle mirror which I find extremely helpful to 
monitor what is happening in back of me and I have no difficulty nor do 
other bioptic users I have interviewed. The vibration does not bother 
me since my brain has learned by some mechanism which I don't understand 
to compensate for it. Before I drove, I rode as a passenger using a 
20x pair of binoculars, something most normally sighted persons can't 
use without a tripod! My hypothesis is that the image blur caused by a 
shaking of the magnification device produces a somewhat less resolved 
image which is what my brain is accustomed to interpreting. Similarly 
the telescopic parallax is not a problem because once again the brain 
has learned to compensate for it. I might compare this adaptation with 
learning to judge depth monocularly which many low vision patients do 
by necessity due to suppression. We don't understand how monocular 
depth perception operates, but we can determine its presence merely by 
observing a person moving safely through space. 

Movement of an image in the opposite direction of head movement is 
experienced by everyone and with no serious complications which I am 
aware of. Why then are these situations, which are cited as problems 
by others, not experienced as problems by low vision patients? 
Probably because all persons citing these areas as problems don't have 
low vision themselves and can't compensate or adapt because they are 
comparing this synthetic situation with their personal experience of 



21 



normal vision and this is obviously not a valid comparison. In short, 
these are problems for the normally sighted person who tries to simulate 
using a bi optic and hence it is concluded that it's a problem for low 
vision patients as well. 

No one is suggesting that low vision is as good as normal vision 
for driving. Of course there is a disadvantage, but this isn't the 
issue. The issue is whether this disadvantage is insurmountable to the 
point where a low vision patient cannot operate a motor vehicle safely. 

No one is arguing the point that there are many poor drivers on 
the road already, so putting a few more marginal persons on the road 
wouldn't hurt. Nor are we trying to consider here the social questions 
of whether it is in the best public interest to license low vision pa- 
tients so they can be gainfully employed and be removed from the welfare 
rolls, or licensing persons with low vision to drive and risking possible 
harm to society. We want to be sure, as sure as we are when we issue a 
license to the normally sighted driver, that the low vision driver has 
the ability through one means or another to drive safely. 

Adaptation methods for using the bioptic and training sequences 
which have been used successfully 1) master fixation on stationary ob- 
jects while not moving; 2) master fixation on moving targets while not 
moving; 3) master fixation on moving targets while moving; 4) develop 
visual discrimination and selectivity and visual memory; have been re- 
ported elsewhere. So have other compensatory mechanisms such as using 
auditory cues, using non-optical aids such as visors, sunglasses, 
tinted windshields, etc., and good defensive driving habits: 1) Get 
the big picture; 2) Keep your eyes moving; 3) Look far ahead in steer- 
ing; 4) Be sure you are seen; 5) Leave yourself an escape if all else 
fails--they have all been discussed at length and their importance 
emphasized. (Kelleher^) 

What I hope has become clear by now to you is that there are 
several similarities between the low vision driver who is merely a per- 
son who must compensate for reduced central acuity, and the normally 
sighted driver. These may be summarized as follows: 

1. Both outdrive their static visual acuity safely. A prime 
example is the normally sighted person with 20/20, at night 
may have only 20/40 or even less. Depending upon the 
etiology, the low vision patient may lose some acuity but 
he may not feel as handicapped because he is accustomed to 
dealing with low acuity and since fovea! vision is primarily 
what is lost, which is something a low vision person doesn't 
have to lose, the same degree of disability may not exist. 

2. Both drive with peri-foveal vision most of the time. 

3. Both ignore scotomas within the visual field safely. 

4. Both see with their brain. 



22 



5. Both use non-visual cues, although in differing amounts. 

6. Botn want to avoid injuring others as well as himself. 

It is true that no one presently has statistically significant 
data and that both viewpoints base their opinion on educated guesses 
and personal experience, but it is difficult to deny empirical ob- 
servation, i.e., those few who are and have been driving safely with 
low vision. We can't get the data unless we license low vision 
drivers. The criticism that the sample is small and that persons are 
driving with different circumstances and different amounts of exposure 
is certainly valid. Therefore, in order to collect the necessary 
data, I believe we must license other low vision drivers, but we must 
exercise the utmost caution and be highly selective in choosing 
prospective drivers. The primary objective, of course, being to expand 
our knowledge regarding the role of vision in driving safety which will 
be mutually beneficial to everyone. 

REFERENCES 



1. Thomas, E. Llewellyn: "Movements of the Eye," Scientific 
American. June, 1974, pp. 2-9. 

2. Kalunger, N. A., and Smith, G. L.: Driver Eye Movement Pat- 
terns Under Conditions of Prolonged Driving and Sleep Deprivation. 
Highway Research Board, 1970. 

3. Henderson, R. L., and Burg, A.: Vision and Audition in 
Driving. Systems Development Corporation, April 1974. 

4. Kelleher, D. K. : "Experience of a Low Vision Patient Driving 
With A Bioptic Telescope," Low Vision , (Ed) Faye & Hood. Springfield, 
Illinois. Charles C Thomas Publishers, ch XXIII. cl975. pp. 189-199, 



23 



PRACTICAL CONCERNS IN DRIVING WITH SUBNORMAL VISION, 
CRITERIA FOR INTRODUCING NEW DEVICES 



Arthur H. Keeney, M.D., D.Sc. 



INTRODUCTION 

To achieve the most efficient and safest operation of a motor vehi- 
cle it is essential to have the input of a suitable and rapid Management 
Information System. The overwhelming majority of such information for 
motor vehicle control is visually derived; consequently at least normal 
levels of visual function have been sought as minimal operational re- 
quirements. Therefore, to operate a motor vehicle or an aircraft with 
subnormal vision has been reasoned to reduce or compromise the informa- 
tional input on which vehicle control is dependent. ' 

Statutes in each of our 50 states require motor vehicle licensing 
authorities to decline license applicants who have physical or mental 
defects which would limit their functional capacity to drive. Medi- 
cally, such problems, large or small, have been called "driver limita- 
tions." 2 

Though normal and optimal physical functions have long been estab- 
lished in many parameters of activity, there is essentially no data on 
which to base the minimal permissible physical capacity for driving. 3 
Thus a person with one lung, one ear, one arm, or one eye may be able 
to propel and guide a motor vehicle but may be sorely taxed in certain 
periods of stress, adverse weather conditions, or crisis. There is some 
information that the monocular driver has a several fold increased fre- 
quency of crashes^ and indeed is more vulnerable on the side without 
vision. 5 Motor vehicle screening tests of visual function are generally 
static procedures done in offices and the results may not correlate 
as well with crash records of driving as do special investigative tests 
which measure the ability to see and react under movement. 6 

The licensing of individuals who must wear relatively conventional 
spectacles to have average normal central acuity has been accepted as 
commonplace and usually does not disqualify the spectacle-wearing ap- 
plicant from driving.'' The use of other optical devices as telescopes, 
binoculars, spotting scopes, or magnifying devices has not been serious- 
ly considered until William Feinbloom, O.D., evolved his spectacle 
mounted "Bioptic" Galilean telescopes. These may distinctly help a 
candidate with visual impairment who is seeking to visualize or resolve 
the test type or test targets used to measure central visual acuity of 
a license applicant. Such magnifying telescopes actually make the 
targets or test devices appear two to four times larger than the format 
in which they are printed or reproduced. Although an applicant may 
thereby seem to have enhanced visual function, the device itself poses 

25 



several optical limitations and is being applied primarily in a fixed or 
static test rather than under the rapidly changing environment of the 
road. The optical limitations of magnifying devices begin with an in- 
herent reduction in the amount of visual field encompassed. This is in 
proportion to the amount of magnification achieved. Thus, under a high 
power microscope only a minute area can be examined. These limitations 
have been detailed in earlier publications. 8 

Though William Feinbloom, O.D., and several optometric groups have 
sought to obtain driver licensing for individuals wearing such telescopes, 
my own interest has only been brought to this issue since 1972. I have 
worn and studied visual field constraints with these devices as marketed 
in the early 1970s and with subsequent models made available to me by 
William Feinbloom in 1976. The physical presence of the device in the 
upper part of the spectacle lens creates an obstruction of the visual 
field even when the driver is not looking through the device or in 
actuality is looking under the device. This is shown in Figure 1 with 
the 2.2xFeinbloom telescope as the patient looks under the bioptic. 
With the same device (2.2x), Figure 2 shows the limit of the magnified 
central area and the breadth of the defect as measured with a 2mm. white 
Lumiwand at one meter. Using the 3x more recently developed "wide angle 
telescopic system," Figure 3 shows the impediment of the upper field 
when the observer is looking beneath his telescope and Figure 4 shows 
the larger scotoma when the patient is looking through the telescope. 
Using the 2.2x current model "wide angle telescopic system," Figure 5 
shows the slightly broader area of central magnification extending 8 or 
9 degrees to either side of fixation but surrounded by even larger sco- 
toma which obscures the entire tangent screen. 

A peripheral obstacle is further added by the carrier lens eye wire 
and the anterior portion of the spectacle temple. If these fall in the 
position to block side vision or if the temple is yery thick, the 
limitation of the bioptic is compounded. Similar concerns apply to 
certain hair styles, massive configuration of the brow and recession of 
the globe which occurs in fat absorption of yery advanced years, or re- 
laxation of the lid tissues with overhanging folds of lid skin. 9 

Military studies during World War II have also established concerns 
over the smearing of visual information as influenced by the speed of 
movement of the observer. Daniel son in 1956 added the terms "speed 
smear" to describe this peripheral blurring which spreads centrally 
with increasing velocity.^ His illustration schematizes a concentric 
reduction in field diameter roughly proportional to increasing velocity. 
Intensity of speed smear is also increased by reduction in size of the 
stimulus, by limitation of its brightness, by increasing proximity and 
by increasing dioptric power of spectacles as worn. Thus, with in- 
creasing velocity there will approach a theoretical locus at which the 
smearing may advance to the ring scotoma of the telescopic device and 
functionally blur out useful peripheral vision. 

PRINCIPLES FOR INTRODUCTION OF NEW MODALITIES 

At introduction of new operations, drugs, lens systems, or tech- 

26 



niques of treatment, several basic components should enter the judgment 
to accept such a device. The more important of these are listed below: 

1. Physiologic basis for introduction: Generally new techniques 
must be compatible with known factors fundamental to normal physiology 
and function. Thus a logical hypothesis rather than an illogical one 
should be constructed for change. 

2. Absence of overriding destructive or damaging elements: 
Limitations and disadvantages introduced by the new technique should 
appear less significant than the proposed advantages. Existing or known 
useful functions should not be destroyed in order to achieve newly pro- 
posed functions. 

3. The absence of data cannot be considered as a logical base: 
Thus, the absence of crash records cannot be used to justify by logic 
or inference the development and introduction of a new technique. 

4. Population groups projected as suitable for the new technique: 
The most valuable and significant agents usually are projected to assist 
the more severe problems or the higher risk individual. If a new pro- 
cedure can be applied only to very minor or limited risk groups its 
ultimate value is distinctly less. 

5. Functional levels sought: The basis of meeting normal and 
literate requirements for function should be delineated by advocates 

of new procedures. Thus, in motor vehicle driving it is basic to estab- 
lish visual resolving powers that can detect and interpret standard 
freeway control signs as designed by the National Committee on Signs, 
Signals, and Markings or by the Bureau of Public Roads. In general, 
these have been engineered to be seen by a driver with at least 20/40 
acuity and to be seen far enough ahead to provide time for interpreta- 
tion and corrective maneuvers under usual traffic speeds and weather 
conditions J 1 

6. Origin of need: In general, most urgent and valid advances 
come from field needs rather than the imposition of a device or pro- 
cedure onto the field from other sources. 

7. Training and educational requirements: New devices should 
progressively lend themselves to introduction and use with minimal 
periods of instruction. For large numbers of citizens to avail them- 
selves of new procedures they must be easily understood and quickly 
applied without prolonged training. Thus, new cameras introduced into 
the market have simplified controls and require little training. 

CONCLUSIONS 

Although spectacle mounted telescopes are being advanced by their 
manufacturers as an aid in passing static central visual screening for 
driver licensing and as spotting aids on the road, there has been 
essentially no field use demand coming from road needs. Modifications 



27 



introduced into the product as marketed do not significantly reduce the 
ring scotoma created by the telescope mounting. Moving pictures taken 
through the device clearly show the extent of the scotoma as much larger 
than the magnified central area. This scotoma permits pedestrians, 
vehicles, and larger traffic to disappear within the scotoma and reappear 
in altered size or distance impressions. Drivers using these devices 
have indicated that they are not used consistently on the road and there- 
fore such drivers are operating motor vehicles with inability to re- 
solve visual cues smaller than those approximating 20/100 to 20/200. 

The optical limitations created include image displacement in the 
opposite direction to any head movement; this is in proportion to the 
degree of magnification. True stereopsis is not a remote visual range 
function and therefore the effect of these devices is not appropriately 
weighed by their role in stereopsis. 

Use of such devices on our congested and lethal highways poses an 
added risk of not seeing small objects such as animals or children 
moving from between parked cars or appearing unexpectedly in cross traf- 
fic patterns. The driver limitation as created by these optical con- 
cerns will compound other minor or major driver limitations such as re- 
duced head movement by arthritis of the spine, reduced visual field due 
to deeply positioned eyes, visual field impairment by overhanging skin 
of the lids or ptotic lids, or slowed reaction time commonly associated 
with advancing years. 



Keeney - Fig. 1 . 



Keeney - Fig. 2. 





"7 \ j<? .-•' /r~~. 


ua i 




Visual field impairment was created by 
Feinbloom Bioptic 2.2x Telescope mounted 
in carrier spectacle lens, while wearer 
is looking beneath the device. Field is 
measured with 2 mm. white Lumiwand at 
1 m. test distance. 



Visual field impairment as created by 
Feinbloom Bioptic 2.2x Telescope mounted 
in carrier spectacle lens, while wearer 
is fixing centrally through the device. 
Field is measured with 2 mm. white 
Lumiwand at 1 m. test distance. 



28 



Keeney - Fig. 3. 



Keeney - Fig. 4. 



x/X/ w^tns/ 


VApD 


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Visual field impairment as created by 
Feinbloom Bioptic 3x "Wide Angle Tele- 
scopic System" mounted in carrier spec- 
tacle lens, while wearer is looking be- 
neath the device. Field is measured 
with 2 mm. white Lumiwand at 1 m. test 
distance. 



Visual field impairment as created by 
Feinbloom Bioptic 3x "Wide Angle Tele- 
scopic System" mounted in carrier spec- 
tacle lens, while wearer is fixing 
centrally through the device. Field is 
measured with 2 mm. white Lumiwand at 
1 m. test distance. 



Keeney - Fig. 5. 




Visual field impairment as created by 
Feinbloom Bioptic 2.2x"Wide Angle Tele- 
scopic System" mounted in carrier spec- 
tacle lens while wearer is fixing 
centrally through the device. Field is 
measured with 2 mm. white Lumiwand at 
1 m. test distance. 



29 



REFERENCES 



1. Visual Factors in Transportation Systems, Washington, D.C., National 
Academy of Sciences-National Research Council, 1969, p. 131. 

2. Medical Aspects of Driver Limitation, Committee on Medical AsDects 

of Automotive Safety, American Medical Association, JAMA, Feb. 1, 1964, 

3. Liesmaa, M.: The Influence of a Driver's Vision in Relation to His 
Driving. Kirapaino Printing, Helsink, 1973. 

4. Keeney, A. H.: Ophthalmic Pathology in Driver Limitation, Trans- 
actions of the American Academy of Ophthalmology and Otolaryngology. 
72:737-740 (September-October) 1968. 

5. Freytag, E., & Sachs, J. G.: Abnormalities of the Central Visual 
Pathways Contributing to Traffic Accidents, JAMA, 204:119-121 
(June 3) 1968. 

6. Berg, A.: Vision Test Scores and Driving Record: Final Report 
(No. 68-72), Institute of Transportation & Traffic Engineering, Los 
Angeles (December) 1968. 

7. Visual Factors in Automobile Driving and Provisional Standards, 
Committee on Medical Aspects of Automotive Safety, Archives of 
Ophthalmology 81:865-871 (June) 1969. 

8. Keeney, A. H., Weiss, S., & Silva, D.: Functional Problems of 
Telescopic Spectacles in the Driving Task, Transactions of the 
American Ophthalmol ogical Society 72:132-146, 1974. 

9. Kite, C. R. & King, J. N.: A Survey of Factors Limiting the 
Visual Fields of Motor Vehicle Drivers in Relation to Minimum 
Visual Fields and Visibility Standards, British Journal of 
Physiological Optics 18:85-107 (April) 1961. 

10. Danielson, R. W.: Relationship of Fields of Vision to Safety in 
Driving, Transactions of the American Ophthalmol ogical Society 
54:369-415, 1956. (81 to E. F. Hockenbreamer 1952 is a secondary 
source) 

11. Forbes, T. W.: Factors in Visibility and Legibility of Highway 
Signs and Markings, in Visual Factors in Transportation Systems. 
Washington, D.C., National Academy of Sciences-National Research 
Council, 1969, pp. 12-29. 



30 



RECOMMENDATIONS 



RECOMMENDATIONS 



Since sufficient statistical data correlating the potential risk 
of driving with telescopic devices is not available, Conference 
participants were reluctant to make specific recommendations to driver 
licensing agencies. However, in view of the fact that at least 20 
states already license wearers of telescopic devices, without adequate 
criteria on which to base such licensure, it was agreed that some 
general guidelines had to be offered until sound data is gathered. 

The goal of the American Medical Association and the American As- 
sociation of Motor Vehicle Administrators in initiating a "Conference 
on Telescopic Lenses and Driver Licensing" was to assist state li- 
censing officials and their medical advisory boards concerning the li- 
censing of wearers of telescopic spectacles. However, much of the dis- 
cussion at the Conference tended to relate to the overall problems of 
low vision and driving, including a discussion of present acuity stan- 
dards and the importance of acuity in driving. While inquiry into basic 
standards and practices is always needed, the Recommendations deal first 
with research on telescopic devices and driving. We feel this approach 
is justified; since the Conference was convened for that purpose, and 
it is the only way in which the safety or hazards involved in the use 
of such devices can be determined. Also, this is the information li- 
censing officials need at this time. However, because of the conten- 
tion by some workshop participants that present acuity standards in 
almost all states are higher than needed for safe driving, the Recom- 
mendations do cover a larger scope than the use of telescopic devices. 

1. No individual should be licensed to drive unless able to meet 
the state's legal requirements for visual acuity without the aid of a 
telescopic device. 

2. To determine if such devices can be used safely under dynamic 
traffic conditions, states that have the facilities, funds and quali- 
fied personnel to conduct scientific research should select highly 
motivated wearers of telescopic devices to take part in a carefully 
controlled, long-range, scientific study. 

3. To determine if state visual acuity requirements are stricter 
than needed for safe driving, a number of other highly motivated 
drivers who, because of their low vision, cannot meet those require- 
ments, would also take part in studies, but would drive without the aid 
of telescopic devices. 

4. All such research should be conducted by trained and recog- 
nized scientific researchers who can assure that it will be scientifi- 
cally sound, and it should be designed to follow driving records, in- 
cluding mileage and type of driving, for a period of not less than five 



33 



years. Individuals selected must have: 

a. a static acuity of at least 20/40 in the better eye through 
the telescope (not applicable to those under Recommendation 

#3); 

b. a best corrected vision through the carrier lens of at least 
20/100 in the better eye; 

c. a minimum of 130° field of vision; 

d. statements from an ophthalmologist or optometrist as to the 
nature of the visual deficiency and whether or not the condi- 
tion is stable; 

e. an evaluation by the driver licensing agency's Medical Ad- 
visory Board; 

f. the ability to pass whatever requirements the state might 
have for any other driver, including a behind-the-wheel test 
that demonstrates skill in driving the vehicle safely and in 
coping with the visual deficiency; and 

g. an annual re-examination, both for visual and practical skills 
in driving. 

5. The research should be overseen by the Medical Advisory Board, 
which should also develop the forms used in selecting the participants, 
especially the form to be completed by the applicant's vision specialist, 

6. Special driver improvement analysts and driver examiners 
should be selected and trained to screen individuals who are to 
participate in the studies. 

If these recommendations are carried out, a start can be made at 
providing adequate criteria to licensing agencies to use in determining 
the safety of licensing wearers of telescopic devices and other 
individuals with low vision. 

(Note: The foregoing Recommendations were developed in the following 
manner: Each of the workshops independently developed a set of 
recommendations. While there were some differences, both groups agreed 
that further study and research was needed. The main disagreement con- 
cerned the means of accomplishing such research. To forestall a great 
deal of bickering and the development of minority reports, an ad hoc 
committee, consisting of the overall chairman, speakers, workshop 
chairmen, and one or two other knowledgeable persons, got together for 
a meeting early on the morning of the second day, and pounded out a 
compromise proposal to present to the overall group. Except for minor 
changes in wording, the above Recommendations are the result.) 



34 



App. A 



(Note: The following unnumbered references were not referred to 
specifically by speakers, but came up frequently in the Conference 
discussions, or were presented to the Conference participants in ad- 
vance as background. All of them can help in gaining an understanding 
of the advantages and disadvantages of telescopic devices.) 



Jose, Randall T., and Butler, James H.: "Training a Patient to Drive 
with Telescopic Lenses," American Journal of Optometry and Physiological 
Optics , Volume 52, May 1975. 

Keeney, Arthur H., and Hames, Lee N.: "Establishing Vision Standards 
for Motor Vehicle Operators," Current Medical Dialog , August 1973. 

Keeney, Arthur H., Weiss, Sidney, and Silva, David: "Telescopic 
Spectacles and Motor Vehicle Driving Licensure," Proceedings, 18th 
Annual Conference, American Association for Automotive Medicine, Morton 
Grove, Illinois, September 1974. 

Levin, Milton, and Kelleher, Dennis K.: "Driving with a Bioptic 
Telescope: An Interdisciplinary Approach," American Journal of Optometry 
and Physiological Optics , Volume 52, March 1975. 



36 



App. B 



REPORT ON 1975 NEW YORK 
TELESCOPIC LENS SYSTEM AND DRIVER LICENSING WORKSHOP* 

This Symposium on Telescopic Lens Systems and Driver Licensing was 
conducted under the auspices of the New York State Department of Motor 
Vehicles to gather opinions and facts about the use of telescopic lens 
systems for driving, and to provide guidance to the Department. 

The use of bioptic telescopic systems for driving has become a 
controversial issue, and the Conference planners tried to convene a 
forum of all opinions on the matter. Unfortunately, the Conference 
did not attract sufficient expertise to present the limitations in- 
herent in the use of these prosthetic devices for driving. In an 
attempt to remedy this lack, the report on the Conference included a 
review of the general literature on the subject— unfortunately, not a 
yery large amount is available, and also little of the research it 
discusses was conducted in a dynamic environment. 

The primary issues to which the participants addressed themselves, 
as published in the proceedings of that Workshop, were the role of 
good central acuity in driving safely, and the ability of telescopic 
wearers to adjust adequately to the prosthetic device. It was ap- 
parently felt that the vast majority of driving does not require the 
resolution of small details, and that good central acuity is required 
only for reading signs or identifying distant objects. It was felt 
also that, through training and experience, the telescopic portion of 
the bioptic could be used safely for all driving tasks that require 
good acuity. Some attendees felt that peripheral vision was probably 
more important to driving than acuity, and a low vision person depends 
more upon his peripheral vision than acuity. Other participants, how- 
ever, emphasized that the low vision of the driver who is not focusing 
through the telescopic lens (which apparently is most of the time) is 
inadequate to warn the driver of potential hazards, and that the dif- 
ficulties in shifting to and from the telescope make it an unacceptable 
alternative to good acuity. 

While the Conference came to no clear consensus, the report 
generally concluded that bioptic telescopic lens systems may be able 
to provide a viable alternative to good central acuity as it is 
needed and used in driving. In addition, it was felt that while the 
device does have some deficiencies, most drivers could learn to adapt 
to them. 



*(Staff-prepared brief summary of 36-page Workshop Report "Telescopic 
Lens Systems and Driver Licensing," prepared by Safety Management 
Institute, Washington, D.C., for the New York State Department of Motor 
Vehicles.) 



37 



It was also felt that there is no evidence that the safety record 
of telescopic wearers is any worse than that of normally sighted drivers, 
but also that there is not enough evidence to support uncontrolled un- 
restricted licensure of telescopic wearers. Based on this, the Work- 
ship recommended that the New York State Department of Motor Vehicles 
undertake a carefully controlled and documented program of licensure 
for telescopic wearers. The following recommendations were made per- 
taining to the requirements to be met before a person is licensed. The 
wearer must have: 

1. the ability to pass the present static acuity test of 20/40 
through the telescopic portion of the device; 

2. a best corrected vision, through the carrier lens, of 20/160 
or better; 

3. at least a 130° field of view with the bioptic in place; 

4. a statement from a licensed practitioner as to the nature of 
his visual deficiency and stating that the condition is stable; 

5. a statement from a licensed practitioner that he has received 
competent training in the use of the device in a dynamic environ- 
ment; 

6. the ability to pass a road test demonstrating his skill in 
driving a vehicle and coping with the device; 

7. an annual reexamination, both for vision and practical skills 
in a road test; and 

8. used the device for a minimum period of time, probably two 
months. 

In addition, it was recommended that the Department of Motor 
Vehicles should: 

1. provide a special form to be completed by a vision specialist 
for each bioptic wearer who applies for a license; 

2. flag the driving record of all individuals who are issued li- 
censes under this program; 

3. train all, or selected, driver license examiners in what to 
look for when testing a bioptic wearer; and 

4. work with the Department of Education, or other appropriate 
agencies, to develop a driver education and training program for 
bioptic lens wearers. 



38 



PARTICIPANTS 



App. C 



Merrill J. Allen, O.D., Ph.D. 
Professor of Optometry 
Indiana University 
School of Optometry 
800 East Atwater 
Bloomington, Indiana 47401 

Frank D. Altobelli, Chief 
Driver Licensing and 

Adjudication Division 
U.S. Department of 

Transportation 
National Highway Traffic 

Safety Administration 
Washington, D.C. 20590 

Alan Barnert, M.D. 

New York Association for 

the Blind 
111 East 59th Street 
New York, New York 10022 

Bruce B. Blasch, Ph.D. 
Executive Director 
American Association of 

Workers for the Blind, Inc. 
1511 K Street, N.W. 
Washington, D.C. 20005 

E'lise Brown 

Driver Education Coordinator 

Sharp Health School 

4300 13th Street, N.W. 

Washington, D.C. 20011 

Russell I. Brown 

President 

Safety Management Institute 

7979 Old Georgetown Road 

Bethesda, Maryland 20014 

Charles Cummins, O.D. 

2421 79th Avenue 

Philadelphia, Pennsylvania 19150 



Thomas G. Dickinson, M.D. 
1880 Arlington Street 
Suite 301 
Sarasota, Florida 33579 

William Feinbloom, Ph.D., O.D. 

138 East 36th Street 

New York, New York 10016 

Gerald E. Fonda, M.D. 

551 Mi 11 burn Avenue 

Short Hills, New Jersey 07078 

William H. Franey 

Assistant Executive Director 

American Association of Motor 

Vehicle Administrators 
1201 Connecticut Avenue, N.W. 
Washington, D.C. 20036 

H. E. Gillespie, M.D. 
Assistant Commissioner for 

Special Health Services 
Commonwealth of Virginia 
Department of Health 
Richmond, Virginia 23219 

Kenneth Hackman 
Safety Management Institute 
7979 Old Georgetown Road 
Bethesda, Maryland 20014 

Lee N. Hames 
Meeting Coordinator 
American Medical Association 
Department of Health Education 
535 North Dearborn Street 
Chicago, Illinois 60610 

George Hel linger, O.D., Director 
I.H.B. Op tome trie Service 
Industrial Home for the Blind 
57 Willoughby Street 
Brooklyn, New York 11201 



39 



Mi 1 o Hodgson, Chief 

Driver Examination and Improvement 

Division of Motor Vehicles 

Department of Transportation 

4802 Sheboygan Avenue 

Madison, Wisconsin 53702 

Wayne Hoeft, O.D. 

Chief, Low Vision Services 

Southern California College of 

Optometry 
2001 Associated Road 
Fullerton, California 92631 

Robert W. Hollenhorst, M.D. 

Secretary-Treasurer 

The American Ophthalmological 

Society 
Mayo Clinic 
200 First Street, S.W. 
Rochester, Minnesota 55901 

Earle L. Hunter, O.D., Director 
Professional Development Division 
American Optometric Association 
700 Chippewa Street 
St. Louis, Missouri 63119 

Paul V. Joliet, M.D. 

Health Officer 

Washington County Health Department 

P.O. Box 2067 

Hagerstown, Maryland 21740 

Randall T. Jose, O.D. 
Center for the Blind 
36th and Lancaster Avenue 
Philadelphia, Pennsylvania 19104 

Arthur H. Keeney, M.D. 
Dean, School of Medicine 
University of Louisville 
Louisville, Kentucky 40202 

Dennis K. Kelleher, Ed.D. 
Director, Low Vision Clinic 
Visual Service Center 
2750 - 24th Street 
Sacramento, California 95818 



Joel A. Kraut, M.D. 

Director, Low Vision Center 

Massachusetts Eye and Ear Infirmary 

c/o 209 Harvard Street 

Brook! ine, Massachusetts 02146 

Donald C. Lhotka, Manager 
Traffic Department 
National Safety Council 
425 North Michigan Avenue 
Chicago, Illinois 60611 

Mrs. Lorraine H. Marchi 
Executive Director 
National Association for 

Visually Handicapped 
305 East 24th Street 
New York, New York 10010 

Kenneth J. Myers, Ph.D., O.D. 
Director of Optometry 
Veterans Administration 
Department of Medicine and 

Surgery 
Washington, D.C. 20420 

J. D. Newman, O.D. 

Land 0'Lakes Plaza 

U.S. Highway 41 

Land 0'Lakes, Florida 33539 

Abe L. Pagoda, O.D. 

30 Ledgewood Road 

Framingham, Massachusetts 01701 

Walter Patterson, M.D. 

2000 Massachusetts Avenue, N.W. 

Washington, D.C. 25036 

Victor J. Perini , Jr. 
Assistant Manager 
Highway Safety Department 
Highway Users Federation 
1776 Massachusetts Avenue, N.W. 
Washington, D.C. 20036 

Robert R. Perlin, O.D. 

Chapel Square 

900 Chapel Street 

New Haven, Connecticut 06510 



40 






Elaine Petrucelli 
Assistant for Safety Education 
Department of Health Education 
American Medical Association 
535 North Dearborn Street 
Chicago, Illinois 60610 

Beth J. Phillips 
Project Director 
Low Vision Services 
American Foundation for 

the Blind, Inc. 
15 West 16th Street 
New York, New York 10011 

Theodore R. Pinckney, M.D. 
Medical Officer 

Bureau of Motor Vehicle Services 
301 C Street, N.W. 
Washington, D.C. 20001 

Harvey I. Remmer, M.D. 

Director 

Division of Health Care Standards 

and Regulation 
Department of Public Health 
80 Boylston Street 
Boston, Massachusetts 02116 

Rose Rennie 

U.S. Department of 

Transportation 
National Highway Traffic 

Safety Administration 
Washington, D.C. 20590 

Basil Y. Scott, Ph.D. 
Administrative Director 
State of New York 
Department of Motor Vehicles 
Empire State Plaza, South Mall 
Albany, New York 12228 

John D. States, M.D. 
1425 Portland Avenue 
Rochester, New York 14608 



Jerry Tannahill 

Highway Safety Management Specialist 

Driver Licensing and 

Adjudication Division 
U.S. Department of Transportation 
National Highway Traffic 

Safety Administration 
Washington, D.C. 20590 

Arthur A. Tritsch 

Director 

Driver Services Division 

American Association of Motor 

Vehicle Administrators 
1201 Connecticut Avenue, N.W. 
Washington, D.C. 20036 



Carter B. Tallman, M.D. 
50 Prospect Street 
Lawrence, Massachusetts 



01841 



41 






HV5701 
P941 


National conference on 
telescopic devices and 
driving. 






DATE DUE 




















— 


HV5701 . 

P941 National conference on 

telescopic devices and |_ 
z < . driving. 


— 


DATE 


ISSUED TO 









— 












_ — 



AMERICAN FOUNDATION FOR THE BUND 
15 WEST 16th STREET 
NEW YORK, N.Y. 10011